What is the next step in management for a patient with a full bladder, damage to the inferior pubic rami, and bruising of the scrotum?

Management of Bladder and Urethral Trauma in Pelvic Fracture with Scrotal Bruising

The next step in management for a patient with a full bladder, damage to the inferior pubic rami, and bruising of the scrotum should be immediate urinary drainage via urethral catheterization or suprapubic catheter placement if urethral catheterization is not feasible. 1, 2

Initial Assessment and Urinary Drainage

Suspected Urethral Injury

• Blood at the external urethral meatus, scrotal hematoma, and perineal bruising with pelvic fracture strongly suggest urethral injury
• Before attempting urethral catheterization in males:
  • Perform retrograde urethrography to rule out urethral injury 1
  • Urethroscopy is an alternative diagnostic option, particularly for penile injuries 1

Catheterization Approach

• If retrograde urethrography shows no urethral injury:
  • Proceed with urethral catheterization
• If urethral injury is confirmed or suspected:
  • Place a suprapubic catheter for urinary drainage 1
  • Avoid blind urethral catheterization which can convert partial urethral tears to complete disruptions

Imaging Workup

Priority Imaging

1. For hemodynamically stable patients:

   • Thoraco-abdomino-pelvic CT scan with contrast to assess all injuries 1
   • CT cystography to evaluate bladder integrity (preferred over conventional cystography) 1

2. For hemodynamically unstable patients:

   • Focused assessment with sonography for trauma (FAST)
   • Pelvic X-ray
   • Defer complete imaging until stabilization
   • Consider immediate suprapubic catheter placement 1

Specific Lower Urinary Tract Imaging

• Not recommended routinely for all pelvic trauma patients 1
• Indicated when there are clinical signs of urinary tract injury:
  • Inability to urinate
  • Gross hematuria
  • Blood at the urethral meatus
  • Suprapubic tenderness
  • Scrotal bruising/hematoma 1

Management Based on Injury Type

Bladder Injury Management

• Intraperitoneal bladder rupture:

  • Requires surgical exploration and primary repair 1

• Extraperitoneal bladder rupture:

  • Uncomplicated cases can be managed non-operatively with urinary drainage 1
  • Complex cases (bladder neck injuries, associated with pelvic fractures) require surgical exploration and repair 1

Urethral Injury Management

• Blunt anterior urethral injuries:

  • Initial conservative management with urinary drainage
  • Attempt endoscopic realignment before considering surgery 1

• Blunt posterior urethral injuries:

  • Initial conservative management with urinary drainage
  • Endoscopic realignment if possible
  • Definitive surgical management should be delayed for 14 days if no other indications for laparotomy exist 1

Time-Critical Considerations

• Time between admission and bleeding control procedures should not exceed 60 minutes in cases with significant hemorrhage 1
• For patients with pelvic fractures and associated hemorrhage, pelvic stabilization (binders or C-clamp) may be required in addition to urinary tract management 1

Follow-up

• Urethroscopy or urethrogram are the methods of choice for follow-up of urethral injuries 1
• CT scan with delayed phase imaging is recommended for follow-up of bladder injuries 1
• Urethrography should be performed every two weeks until complete healing in cases of urethral injury 1

Pitfalls to Avoid

• Never attempt blind urethral catheterization when urethral injury is suspected
• Don't delay urinary drainage in patients with a full bladder and pelvic trauma
• Avoid focusing solely on the pelvic fracture while missing associated urinary tract injuries
• Remember that scrotal bruising with pelvic fracture is highly suggestive of urethral injury
• Don't assume that a stable patient doesn't require thorough evaluation of the urinary tract